Radiology
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Razavi, M. K.
Right arrow Articles by Dake, M. D.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Razavi, M. K.
Right arrow Articles by Dake, M. D.
(Radiology. 2000;214:133-138.)
© RSNA, 2000

Vascular and Interventional Radiology

Chronically Occluded Inferior Venae Cavae: Endovascular Treatment1

Mahmood K. Razavi, MD, Ernst C. Hansch, MD, Stephen T. Kee, MD, Daniel Y. Sze, MD, Charles P. Semba, MD and Michael D. Dake, MD

1 From the Department of Radiology, Division of Cardiovascular-Interventional Radiology, Stanford University Hospital, Ste H-3651, 300 Pasteur Dr, Stanford, CA 94305-1056. Received November 19, 1998; revision requested December 22; revision received April 1, 1999; accepted May 25. Address reprint requests to M.K.R. (e-mail: mrazavi@stanford.edu).


   Abstract
TOP
 Abstract
Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
PURPOSE: To report the results of endoluminal recanalization and stent placement in patients with chronic occlusions of the inferior vena cava (IVC).

MATERIALS AND METHODS: Seventeen consecutive patients (12 male, five female patients; mean age, 40.6 years; age range, 15–77 years) with chronic IVC occlusions were treated during a 6-year period. The mean duration of symptoms was 32 months. Underlying active malignancy was the cause of occlusion in four patients. Five patients with superimposed acute thrombus underwent catheter-directed thrombolysis prior to IVC recanalization. Clinical patency was defined as absence or improvement of symptoms. Clinical follow-up was supplemented with ultrasonography, vena cavography, or both in 10 patients.

RESULTS: Technical success was achieved in 15 (88%) patients. Additional thrombolytic therapy and stent placement was needed in two patients to maintain patency at 4 and 6 months after the procedure. Twelve patients had IVCs that remained patent after a mean follow-up of 19 months for a primary patency rate of 80%. The primary assisted patency rate was 87% (13 of 15). There were four deaths owing to underlying disease 6–21 months after the procedures. There were no procedure-related complications.

CONCLUSION: Endoluminal recanalization and stent placement in chronically occluded IVCs has a good intermediate-term outcome and should be considered in patients who have symptoms and who often do not have adequate alternative therapy.

Index terms: Venae cavae, grafts and prostheses, 569.126, 949.1268 • Venae cavae, interventional procedures, 569.126, 949.1268 • Venae cavae, stenosis or obstruction, 569.30, 569.40, 949.30, 949.40, 949.72 • Venae cavae, thrombosis, 569.1265, 949.1265, 949.751


   Introduction
TOP
 Abstract
 Introduction
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Thrombosis of the inferior vena cava (IVC) is a rare condition that can result from various underlying disease entities, including hypercoagulability disorders, obstruction due to tumor involvement, IVC interruption by filter or surgery, trauma, inflammation, or infection, or from idiopathic causes (1,2). If untreated, or inadequately treated, this condition may cause debilitating lower extremity pain and swelling, back pain, weakness, and venous stasis ulceration: a constellation of symptoms sometimes referred to as the "IVC syndrome." Disrupted liver and kidney function also can occur if the intrahepatic vena cava or renal veins are involved (1–4). In chronic states, the treatment options in patients with symptoms are limited and thus far have had suboptimal outcome (5). Anticoagulation is largely ineffective in relieving the lower extremity symptoms, and thrombolytic therapy is of value only in acutely thrombosed IVCs. Venous bypass surgery has been the only option in the most severe cases and has had limited efficacy and applicability (6,7). Endovascular stent placement recently has emerged as an effective treatment alternative in caval stenoses and occlusions (8–13). Most articles on the percutaneous therapy of chronically occluded IVCs, however, are limited to case reports or the description of single cases as part of a larger study (9,12,14).

The purpose of this study was to present our experience with endoluminal recanalization of and stent placement in chronically occluded IVCs in 17 patients with symptoms; the objective was to evaluate the feasibility of endoluminal therapy in these patients. To our knowledge, this is the first such report in the literature.


   MATERIALS AND METHODS
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 References
 
Between March 1992 and July 1998, 17 consecutive patients (12 male, five female patients; age range, 15–77 years; mean age, 40.6 years; median age, 30 years) with chronically occluded IVCs were referred for examination. Patients with disease limited to the iliac veins or lower, or those with stenosis or acute thrombosis of the IVC, were excluded from this analysis.

For purposes of this study, chronic occlusion was defined as symptoms, objective imaging evidence, or both of occlusion longer than 3 months in duration. Patients had chronic symptoms of IVC occlusion, including leg swelling, pain and cramps, weakness, lower extremity pigmentation, and decreased exercise tolerance. The mean duration of symptoms was 32 months (range, 1–276 months). Patient characteristics and the causes of IVC occlusions are listed in Table 1. Although patient 14 had symptoms for only 1 month, she was included in this study because she had ultrasonographic (US) evidence of iliocaval occlusion 5 months prior to presentation.


View this table:
[in this window]
[in a new window]

  		TABLE 1. Characteristics of Patients with Chronic IVC Occlusion
 
The risks, benefits, and alternatives of the procedure were explained to all patients, and written informed consent was obtained. The procedures were performed with the use of conscious sedation with intravenously administered fentanyl citrate (Fentanyl; Abbot Laboratories, North Chicago, Ill) and midazolam hydrochloride (Versed; Roche Laboratories, Nutley, NJ). The initial venography was performed through common femoral (n = 13), popliteal (n = 1), and jugular (n = 3) veins. In three of the 14 patients with the initial femoral or popliteal entry, an internal jugular access was also obtained for a cephalic approach. Similarly, in two of the three patients with a jugular approach, an inferior access was also secured.

Patients 1, 4, 6, 14, and 15 were thought to have a component of superimposed acute thrombosis and were first treated with overnight infusion of urokinase (Abbokinase; Abbott Laboratories) at a mean dosage of 130,000 IU/h. The presence of acute clot was determined on the basis of the venographic appearance of thrombosed vein (intraluminal filling defects in expanded vein) and the ease of clot penetration with use of a soft guide wire (guide-wire test). This was limited to either the iliac vein or veins or a combination of the iliac and collateral veins in all five patients.

Recanalization of the chronically occluded venous segments was attempted by using a Berenstein Glidecath catheter and Glidewire (Boston Scientific, Natick, Mass). Two patients required sharp instrument probing with the back end of a wire to connect the short segments (<3 cm) between the superiorly and inferiorly created channels. The wire introduced through the jugular access was then snared from the groin by using a vascular snare (Amplatz; Microvena, St Paul, Minn) to allow femoral access to the entire length of the occluded IVC. The occluded segments were then predilated by using a balloon of smaller caliber than the IVC to allow stent placement. Balloon expandable Palmaz stents (Cordis Endovascular, Warren, NJ) were used in five patients, self-expanding Wallstents (Boston Scientific) were used in eight, and a combination of both stents were used in one (Table 2).


View this table:
[in this window]
[in a new window]

  		TABLE 2. Results of Endovascular Recanalization of Chronically Occluded IVCs in 17 Patients
 
When occlusions or stenoses involved the iliac veins (patients 5, 10, 12, 14, 15, 16, and 17), the stents were extended inferiorly in either a parallel "kissing" fashion (patients 5, 12, 14, 15, and 16) (Fig 1), or they were extended into one iliac system (patients 10 and 17) (Fig 2). The symptoms in patient 10 were due to reduced cardiac preload, and the recanalization of the IVC and one of the iliac veins resolved the symptoms. Patient 17 was a candidate for renal transplantation who had occlusion of the infrahepatic IVC and stenosis within the right iliac vein. Stents were placed in the IVC and right iliac vein to provide good outflow for the planned pelvic renal transplant. This patient's symptoms of lower extremity edema, pain, and pigmentation began after a blunt abdominal trauma 10 years prior to presentation.



View larger version (165K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1. Patient 12. (a) Transverse contrast material-enhanced CT scan of the abdomen in a 60-year-old man shows a surgical clip (curved arrow) that was placed around the IVC 23 years prior to this study to prevent pulmonary embolism. Note the extensive retroperitoneal and subcutaneous collateral veins (straight arrows). (b) Anteroposterior bilateral iliac venogram obtained with the patient in a prone position 6 months after the initial recanalization of the IVC. Iliac venous stents were placed in a "kissing" fashion.

 


View larger version (96K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1. Patient 12. (a) Transverse contrast material-enhanced CT scan of the abdomen in a 60-year-old man shows a surgical clip (curved arrow) that was placed around the IVC 23 years prior to this study to prevent pulmonary embolism. Note the extensive retroperitoneal and subcutaneous collateral veins (straight arrows). (b) Anteroposterior bilateral iliac venogram obtained with the patient in a prone position 6 months after the initial recanalization of the IVC. Iliac venous stents were placed in a "kissing" fashion.

 


View larger version (62K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 2. Patient 10. (a) Anteroposterior digital subtraction vena cavogram in a 40-year-old woman shows occlusion of the IVC with flow through enlarged paralumbar venous plexus (arrows). (b) Anteroposterior digital subtraction cavogram shows widely patent IVC after balloon angioplasty and placement of Wallstents with no evidence of collateral flow. The arrow indicates the uppermost extent of the stents.

 


View larger version (59K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 2. Patient 10. (a) Anteroposterior digital subtraction vena cavogram in a 40-year-old woman shows occlusion of the IVC with flow through enlarged paralumbar venous plexus (arrows). (b) Anteroposterior digital subtraction cavogram shows widely patent IVC after balloon angioplasty and placement of Wallstents with no evidence of collateral flow. The arrow indicates the uppermost extent of the stents.

 
Patient 6 had concurrent acute thrombosis of her left iliac venous system, which resolved after overnight thrombolysis. The occluded IVC segment was recanalized and treated with balloon angioplasty alone, without placement of any stents, at the request of the referring physician and the patient. Satisfactory patency of the IVC was not achieved in this patient owing to venous recoil after balloon angioplasty.

The end point of the procedures in these patients was determined by means of venographic criteria of rapid flow through the created lumina and disappearance of collateral venous circulation.

All patients underwent anticoagulation therapy with heparin sodium (Heparin; Wyeth Laboratories, Philadelphia, Pa) during the procedure and received warfarin sodium (Coumadin; Dupont, Wilmington, Del) to achieve an international normalized ratio, or INR, of 2–3 for at least 4–6 months. Longer anticoagulation therapy was instituted for patients with uncorrectable underlying hypercoagulable states.

Follow-up for these venous interventions consisted of office visits and venous US at 3 months and at 6 and 12 months (± 2 months) after the procedure, and as patient symptoms required thereafter. This follow-up regimen was available in 10 patients. Longer follow-up data for these patients who were also seen in other clinics for various medical conditions were obtained from their medical records. Clinical patency was assessed in five others who lived in distant geographic locations by means of phone conversations with the patients, their private physicians, or both. The remaining two who were not treated successfully were not seen at follow-up.

Follow-up digital subtraction vena cavography was performed in patients 1, 4, 12, and 13 because they were clinically suspected of having restenosis or reocclusion. Technical success was defined as successful passage of the guide wire through the occluded vein, and clinical success was defined as complete resolution of or substantial improvement in patient symptoms.


   RESULTS
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 References
 
The actual time of IVC occlusion could be determined with certainty only in patient 12. Patient 17 probably had IVC thrombosis at the time of abdominal trauma. The actual duration of IVC occlusion in all others is unknown. Thrombolytic therapy in the five patients with a superimposed acute clot was successful in all, with the resolution of acute thrombi. Partial or complete IVC patency, however, was not seen in any of the patients after thrombolysis alone. Endoluminal recanalization attempts were successful in 15 of the 17 patients, which is a technical success rate of 88%.

Patient 9 was one of the two patients with a failed procedure because he had no suitable inferior access owing to long-standing iliofemoral deep venous thrombosis. Efforts to recanalize the entire infrahepatic IVC and iliofemoral venous segments through a jugular access in this patient were unsuccessful. In the other patient, attempts to traverse the occluded IVC from both femoral and jugular accesses failed.

Stents were placed in 14 of the 15 patients who underwent successful recanalization. Fifty-five stents were used in these patients—26 Palmaz stents and 29 Wallstents—and all were balloon dilated after placement. Adjuvant therapy was needed to maintain patency at 6 and 4 months after the procedure in patients 1 and 4, respectively.

Patient 1, who had chronic renal failure, required thrombolysis for a symptomatic left lower extremity iliofemoral deep venous thrombosis, presumably related to her hypercoagulable state. She also had developed right common iliac venous stenosis secondary to placement of a dialysis access graft in her right groin. Stents subsequently were placed in both common iliac veins in this patient.

Patient 4 required another intervention on two different occasions—with iliac venous thrombolysis and with extension of the stents into the iliac and femoral veins. This patient, who also had Behcet disease with recurrent symptoms 6 months after the last intervention, was discovered to have rethrombosis of his iliocaval venous segments. His symptoms gradually improved with anticoagulation therapy and treatment of the underlying Behçet disease.

The only other IVC thrombosis in this series was in patient 6, who had been treated with thrombolysis and angioplasty alone. This patient had no relief of symptoms after the procedure, and follow-up US revealed evidence of IVC reocclusion. This likely occurred owing to venous recoil. All other patients treated successfully had complete or substantial relief of symptoms within 48 hours. Patients 12 and 13 had recurrence of mild lower extremity edema with no evidence of hemodynamically significant in-stent restenosis or rethrombosis at follow-up venography.

Of the 15 patients whose IVCs were successfully recanalized, 12 had IVCs that remained patent without any further interventions for a primary patency rate of 80% after a mean follow-up of 19 months (range, 2–60 months). The primary assisted patency rate among the patients in our study was 87% (13 of 15). There were four deaths (patients 2, 5, 8, and 11) in the follow-up period owing to underlying disease. The deaths occurred 6–21 months after the procedures (mean, 10.5 months). No follow-up data were obtained in patients 7 and 9, whose procedures were the technical failures in this series.

Four patients had transient pain that resolved spontaneously without any specific treatment during balloon angioplasty, stent placement, or both in the IVC. As mentioned earlier, patient 6 had acute reocclusion of the IVC after recanalization. No other complications were encountered in this study.


   DISCUSSION
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
References
 
In patients with symptoms of chronic IVC occlusion, supportive measures are frequently the only therapy offered. This is because of the very invasive nature and associated morbidity of the surgical alternatives. In patients with an unresectable underlying malignancy, the treatment of IVC syndrome is aimed largely at palliation owing to the patient's short life expectancy. The endoluminal approach is often effective in relieving the symptoms in these patients and should be considered the first line of treatment (15–17).

IVC occlusion due to benign causes poses a different clinical challenge, as the maintenance of IVC patency and relief of symptoms should be extended over many years. In our study, there were four patients with active malignancy, and the remaining patients were either in remission or had benign disease. In general, therefore, the procedures were not intended as short-term palliative therapy but rather as a long-term solution for patients with normal life expectancies. In these cases, the surgical approach often is limited by the availability and suboptimal results of appropriate venous conduits and prosthetic grafts (6,7,18,19).

Gloviczki et al (6) in their report on the effectiveness of venous grafting in 28 patients with superior vena caval or iliocaval obstruction concluded that whereas a spiral saphenous venous graft appears to be a good conduit for superior vena caval bypass, its application is limited in IVC obstruction. In their series, 43% of the patients had to undergo additional surgeries, 29% of which were to maintain patency at a median follow-up of 2 years. Of the 11 patients with abdominal or pelvic bypass grafts made of expanded polytetrafluoroethylene, only seven (64%) patients had grafts that were patent after a mean follow-up of 9 months.

Results of angioplasty alone have also been disappointing (20,21). This is particularly true in the setting of chronic venous occlusions due to venous recoil, low flow state, and thrombogenicity of the lumen. The only acute reocclusion of IVC in our series occurred in the patient who was treated with angioplasty alone at the request of the patient and the referring physician.

Stents potentially can improve the outcome of endoluminal interventions in large veins, mainly by preventing recoil. The large venous conduit presumably then would have sufficient flow to maintain patency. This, however, remains largely a theoretic advantage, since caval patency after stent placement for benign disease is not well established in the literature. The issue is better studied in the superior vena cava, where response rates of 68%-100% have been reported (22–25). Most reports in the literature are on patients with malignant superior vena cava syndrome. In the series by Kee et al (22), 16 of the 59 patients treated had benign disease. The primary and secondary clinical patency rates in 13 of these patients who were available for follow-up were 77% and 85%, respectively, after a mean follow-up of 17 months.

There are relatively few published reports on stent placement in the IVC, and the long-term outcome is not well known. Most of these articles are about patients with Budd-Chiari syndrome rather than IVC syndrome, and the chronicity of the process is not well established or reported (26–30).

In the series by Nazarian et al (9), two of the three patients who were treated with IVC stents had occlusions of uncertain duration, and one remained patent at 1 year. Park et al (29) reported stent placement in seven patients with benign segmental obstruction of the hepatic IVC and achieved a primary patency rate of 71% (five of seven) after a mean follow-up of 12 months. Nine of the 10 patients with Budd-Chiari syndrome who were treated by Kaul et al (30) remained symptom free 1–13 months after IVC stent placement. Good clinical outcome of hepatic IVC stent placement was also seen in this series of patients with chronic occlusion of the infrarenal IVC with a primary assisted patency rate of 87% after a mean follow-up of 19 months.

Although the percutaneous recanalization of chronically occluded venous channels can be a difficult and time-consuming task, our attempts were successful in 15 of the 17 patients. Stents remained patent in all but one patient, as described, despite the fact that these slow flow channels were created through organized clot and fibrotic lumina—all conditions that predispose the patient to thrombosis. No arteriovenous fistula to maintain patency was created in this study. In our experience, arteriovenous fistulas have not been necessary in cases in which the treated venous segment has good inflow and outflow.

The anticoagulation regimen used in the patients with no underlying hypercoagulability presumably would allow for reendothelialization of the lumina, which renders them less thrombogenic. Although delayed reendothelialization has been shown to promote intimal proliferation (31–33), the beneficial effects of this short-term anticoagulation protocol on the rate of reendothelialization or rethrombosis remain unproved.

The symptoms of most patients with occlusion of the infrarenal IVC improve beyond the acute phase owing to establishment of collateral pathways. In some, the venous outflow obstruction causes venous hypertension and valvular incompetence over time (5), which leads to recurrence of symptoms. In others, acute thrombosis of iliofemoral veins or collateral circulation may worsen the existing symptoms and cause patients to seek medical attention. In many patients, therefore, there is not a good correlation between the onset of symptoms and the actual thrombosis of the IVC. This was also true in this series. With the exception of patients 12 and possibly 17, the actual time of IVC thrombosis was unknown among these patients.

No complications were encountered in this small series of patients, which confirms the safety of this approach. Specifically, there were no clinically detectable pulmonary emboli, infection, bleeding, hematoma, or stent migration or misplacement. Four patients had pain that resolved spontaneously without any sequelae during balloon dilation and stent placement in the IVC.

The intermediate-term results of the endovascular stent placement in the chronically occluded IVCs reported in this limited number of patients are encouraging. The safety and efficacy of endovascular stent placement offers patients with symptoms of chronically occluded IVC an alternative to both the medical and surgical therapies. Further studies of the long-term outcome in these patients and the influence of factors such as the amount of flow through the stents, the status of competitive flow through the collateral vessels, and the degree of venous reflux on the patency of the created lumina are warranted.


   Footnotes
 
Abbreviation: IVC = inferior vena cava

Author contributions: Guarantors of integrity of entire study, M.K.R., M.D.D.; study concepts and design, M.K.R., C.P.S., M.D.D.; definition of intellectual content, M.K.R., C.P.S., M.D.D.; literature research, M.K.R., E.C.H.; clinical studies, M.K.R., D.Y.S., S.T.K., C.P.S., M.D.D.; data acquisition and analysis, M.K.R., E.C.H., C.P.S.; manuscript preparation, M.K.R., E.C.H.; manuscript editing and review, M.K.R., C.P.S., M.D.D.


   References
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 

  1. Harris RD. The etiology of inferior vena caval obstruction and compression. Crit Rev Clin Radiol Nucl Med 1976; 8:57-86.
  2. Missal ME, Robinson JA, Tatum RW. Inferior vena cava obstruction: clinical manifestation, diagnostic methods, and related problems. Ann Intern Med 1965; 62:133-161.
  3. Sonin AH, Mazer MJ, Powers TA. Obstruction of the inferior vena cava: a multiple-modality demonstration of causes, manifestations, and collateral pathways. RadioGraphics 1992; 12:309-322.[Abstract]
  4. Grossmann K, Heerklotz I, Endert G, Basche S. Verlaufsbeobachtungen beim unteren vena cava inferior-syndrom. Vasa 1983; 12:337-341.[Medline]
  5. Rutherford RB. Pathogenesis and pathophysiology of the post-thrombotic syndrome: clinical implications. Semin Vasc Surg 1996; 9:21-25.[Medline]
  6. Gloviczki P, Pairolero PC, Toomey BJ, et al. Reconstruction of large veins for nonmalignant venous occlusive disease. J Vasc Surg 1992; 16:750-761.[Medline]
  7. Raju S. Experience in venous reconstruction in patients with chronic venous insufficiency: venous disorders Philadelphia, Pa: Saunders, 1991; 296-305.
  8. Charnsangavej C, Carrasco CH, Wallace S, et al. Stenosis of the vena cava: preliminary assessment of treatment with expandable metallic stents. Radiology 1986; 161:295-298.[Abstract/Free Full Text]
  9. Nazarian G, Austin W, Wegryn S, et al. Venous recanalization by metallic stents after failure of balloon angioplasty or surgery: four-year experience. Cardiovasc Intervent Radiol 1996; 19:227-233.[Medline]
  10. Carrasco C, Charnsangavej C, Wright K, Wallace S, Gianturco C. Use of the Gianturco self-expanding stent in stenoses of the superior and inferior venae cavae. JVIR 1992; 3:409-419.[Medline]
  11. Irving J, Dondelinger R, Reidy J, et al. Gianturco self-expanding stents: clinical experience in the vena cava and large veins. Cardiovasc Intervent Radiol 1992; 15:328-333.[Medline]
  12. Elson JD, Becker GJ, Wholey MH, Ehrman KO. Vena caval and central venous stenoses: management with Palmaz balloon-expandable intraluminal stents. JVIR 1991; 2:215-223.[Medline]
  13. Nazarian GK, Bjarnason H, Dietz CA, Jr, Bernadas CA, Hunter DW. Iliofemoral venous stenoses: effectiveness of treatment with metallic endovascular stents. Radiology 1996; 200:193-199.[Abstract/Free Full Text]
  14. Roy S, Baijal S, Rastogi H. Iliocaval reconstruction with metallic stents. Cathet Cardiovasc Diagn 1994; 32:367-371.[Medline]
  15. Tacke J, Antonucci F, Stuckman G. The palliative treatment of venous stenoses in tumor patients with self-expanding vascular prostheses. ROFO 1994; 160:433-440.
  16. Entwisle KG, Watkinson AF, Hibbert J, Adam A. The use of the Wallstent endovascular prosthesis in the treatment of malignant inferior vena cava obstruction. Clin Radiol 1995; 50:310-313.[Medline]
  17. Kishi K, Sonomura T, Nishidi N, et al. Self-expandable metallic stent therapy for inferior vena cava obstruction secondary to malignancy: clinical observations. Nippon Igaku Hoshasen Gakkai Zasshi 1994; 54:389-398.[Medline]
  18. Lalka SG, Malone JM. Surgical management of chronic obstructive venous disease of the lower extremity. In: Rutherford RB, eds. Vascular surgery. 3rd ed. Vol 2. Philadelphia, Pa: Saunders, 1989; 1627-1647.
  19. Wilson SE, Jabour A, Stone RT, Stanley TM. Patency of biologic and prosthetic inferior vena cava grafts with distal limb fistula. Arch Surg 1978; 113:1174-1179.[Abstract]
  20. Davidson CJ, Newman GE, Sheikh KH, Kisslo K, Stack RS, Schwab SJ. Mechanisms of angioplasty in hemodialysis fistula stenoses evaluated by intravascular ultrasound. Kidney Int 1991; 40:91-95.[Medline]
  21. Kovalik EC, Newman GE, Suhocki P, Knelson M, Schwab SJ. Correction of central venous stenoses: use of angioplasty and vascular Wallstents. Kidney Int 1991; 45:1177-1181.
  22. Kee ST, Kinoshita L, Razavi MK, Nyman URO, Semba CP, Dake MD. Superior vena cava syndrome: treatment with catheter-directed thrombolysis and endovascular stent placement. Radiology 1998; 206:187-193.[Abstract/Free Full Text]
  23. Hochrein J, Bashore TM, O'Laughlin MP, Harrison JK. Percutaneous stenting of superior vena cava syndrome: a case report and review of literature. Am J Med 1998; 104:78-84.[Medline]
  24. Martinoli C, Cittadini G, Gandolfo N, Crespi G, De Caro G, Derchi LE. Superior vena cava stents: Doppler US of the internal mammary veins to detect collateral flow—preliminary observations. Radiology 1997; 204:865-870.[Abstract/Free Full Text]
  25. Gross CM, Kramer J, Waigand J, et al. Stent implantation in patients with superior vena cava syndrome. AJR 1997; 169:429-432.[Abstract/Free Full Text]
  26. Gillams A, Dick R, Platts A, Irving D, Hobbs K. Dilatation of the inferior vena cava using an expandable metal stent in Budd-Chiari syndrome. J Hepatol 1991; 13:149-151.[Medline]
  27. Yang XL, Cheng TO, Chen CR. Successful treatment by percutaneous balloon angioplasty of Budd-Chiari syndrome caused by membranous obstruction of inferior vena cava: 8-year follow-up study. J Am Coll Cardiol 1996; 28:1720-1724.[Abstract]
  28. Ishiguchi T, Fukatsu H, Itoh S, Shimamoto K, Sakuma S. Budd-Chiari syndrome with long segmental inferior vena cava obstruction: treatment with thrombolysis, angioplasty, and intravascular stents. JVIR 1992; 3:421-425.[Medline]
  29. Park J, Chung J, Han J, Han M. Interventional management of benign obstruction of the hepatic inferior vena cava. JVIR 1994; 5:403-409.[Medline]
  30. Kaul U, Agarwal R, Jain P, Sharma S, Sharma S, Wasir HS. Management of idiopathic obstruction of the hepatic and suprahepatic inferior vena cava with a self-expanding metallic stent. Cathet Cardiovasc Diagn 1996; 39:252-257.[Medline]
  31. Fishman JA, Ryan GB, Karnovsky MJ. Endothelial regeneration in the rat carotid artery and the significance of endothelial denudation in the pathogenesis of myointimal thickening. Lab Invest 1975; 32:339-351.[Medline]
  32. Haudenschild CC, Shwartz SM. Endothelial regeneration. II. Restitution of endothelial continuity. Lab Invest 1979; 41:407-418.[Medline]
  33. Asahara T, Chen D, Tsurumi Y, et al. Accelerated restitution of endothelial integrity and endothelium-dependent function after phVEGF165 gene transfer. Circulation 1996; 94:3291-3302.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 Palliat MedHome page
H McGee, D Maudgil, A Tookman, A Kurowska, and A F Watkinson
A case series of inferior vena cava stenting for lower limb oedema in palliative care
Palliative Medicine, September 1, 2004; 18(6): 573 - 576.
[Abstract] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Razavi, M. K.
Right arrow Articles by Dake, M. D.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Razavi, M. K.
Right arrow Articles by Dake, M. D.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
RADIOLOGY RADIOGRAPHICS RSNA JOURNALS ONLINE